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Emerald Ridge Health and Rehabilitation

25 Reynolds Mountain Boulevard, Asheville, NC 28804 · For profit - Limited Liability company · 100 certified beds · (828) 645-6619 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Oct 2023Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$73,475 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2023
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $73,475 in federal fines (most recent 2026-04-09)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
61 Weaver Blvd., Weaverville, NC 28787, United States · (828) 645-5088 · Call to confirm hours
Pharmacy
471 Weaverville Rd · (828) 645-2498 · Call to confirm hours
Grocery
83 Weaverville Rd · (828) 645-2506 · Call to confirm hours
Park
200 Weaverville Rd · (828) 254-3708 · Typically dawn to dusk
Place of worship
20 Reynolds Mountain Blvd · (828) 219-3404

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.7%15.6%15.4%better
Long-stay residents who lose too much weight8.0%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection1.3%2.3%2.0%better
Long-stay residents with depressive symptoms0.0%5.9%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened9.6%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.7%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine97.6%94.1%95.3%typical
Long-stay residents with pressure ulcers10.3%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control28.6%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table24.9%14.0%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.1%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine93.4%78.1%79.4%better
Short-stay residents rehospitalized after admission32.4%22.9%22.6%worse
Short-stay residents with an outpatient ER visit4.3%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days3.381.781.67worse
Long-stay outpatient ER visits per 1,000 resident days1.181.801.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.8%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
38.5%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 38.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.8%CMS range 35.4–56.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.1–13.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge38.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge33.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting90.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.1–12.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.831.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.63
RN hours/ resident / day
0.43
LPN hours/ resident / day
2.00
Aide hours/ resident / day
3.06
Total nurse hours/ resident / day
0.52
RN hoursweekends
35.8%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 89.7 residents a day — about 90% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.60 hrs/resident/day on weekends vs 3.25 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.68 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

10
deficiencies at the latest standard inspection (2026-04-09)
9
at the previous standard inspection (2025-03-06)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Immediate jeopardy · J2026-04-09 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, power of attorney (POA), Nurse Practitioners, Psychiatrist and Medical Director, the facility failed to ensure Resident #101, who was admitted on [DATE] following a stay at an inpatient psychiatric facility beginning on 1/9/26 for a severe episode of recurrent major depressive disorder with suicidal behavior with attempted self-injury, received the necessary treatment that was person-centered and individualized to meet her needs. The resident's psychiatric diagnoses included major depressive disorder, post-traumatic stress disorder (PTSD), bipolar disorder, and delusional disorders. The inpatient psychiatric facility's discharge summary included an order for antipsychotic medication (olanzapine) every night at bedtime. This order was inaccurately transcribed as a PRN (as needed) order and was administered once during the resident's stay at the facility. The Psychiatrist from the inpatient psychiatric facility indicated that olanzapine did not work as a PRN…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-03-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff and Wound Care Nurse Practitioner (NP) interviews, the facility failed to assess for and identify a pressure ulcer on the buttock before it was assessed as a stage III (full-thickness loss of skin) for 1 of 2 residents (Resident #10) reviewed for pressure ulcers. Findings included: The hospital Discharge summary dated [DATE] indicated Resident #10 was admitted to the hospital with a left femur fracture and had a surgical procedure to repair her left femur fracture on 2/4/25. The discharge summary reported an x-ray was completed on 2/4/25 that showed a humerus fracture. The discharge summary indicated she had surgical incisions to her left lower extremity. The discharge summary did not mention any other wounds or skin abnormalities. Resident #10 was admitted to the facility on [DATE] with the following diagnoses: unspecified fracture of shaft of left femur, unspecified fracture of upper end of left humerus, and impaired mobility. The admission nursing assessment…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-09 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address concerns voiced by residents during Resident Council meetings for 11 of 12 months reviewed (April 2025, May 2025, June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, January 2026, February 2026 and March 2026).The findings included: A review of the grievance logs from April 2025 to March 2026 showed that no grievances were filed on behalf of the Resident Council from April 2025 to December 2025. Further review of the log revealed grievances filed on behalf of Resident Council in January 2026, February 2026, and March 2026 had no documentation of complaints/grievances, plans to resolve the complaints/grievances or actions taken to resolve the complaints/grievances. The Resident Council minutes dated 4/16/25 and recorded by the Activity Director showed grievances related to housekeeping, dietary, and nursing services. Housekeeping concerns included bathrooms that were not consistently cleaned, delayed trash removal, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and Pharmacist, the facility failed to implement a system to consistently and accurately reconcile controlled medications obtained from home for 1 of 1 resident reviewed for medication management (Resident #8). As a result, a total of 31 tablets of Lorazepam (a controlled medication) were unaccounted for. The facility also failed to keep accurate records of controlled medications for 1 of 2 medication cart narcotic records reviewed.The findings included: 1.Resident #8 was admitted to the facility 1/9/26 for a respite stay with diagnoses that included anxiety disorder. Resident #8 had the following physician's orders for Lorazepam: 1/9/26 - Lorazepam oral tablet (benzodiazepine) one (1) milligram (mg) – give one tablet by mouth every 8 hours as needed for anxiety. This order was changed on 1/12/26 to Lorazepam oral tablet one (1) mg – give one tablet by mouth every 8 hours as needed for anxiety for 14 days. The admission Minimum Data Set (MDS) assessment dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, observations and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions and hand hygiene when Nurse Aide (NA) #8, Medication Aide #1 and NA #10 did not wear personal protective equipment during incontinence care and when NA #8 did not change gloves and perform hand hygiene after contact with a soiled brief. In addition, the Treatment Nurse failed to change her gloves and perform hand hygiene during wound care. This deficiency occurred for 4 of 8 staff members observed for infection control practices (NA #8, NA #10, Medication Aide #1 and Treatment Nurse).The findings included:A review of the facility's policy titled Enhanced Barrier Precautions, revised on 6/4/25, indicated:Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact resident care activities.High-contact activities included dressing, bathing, transferring, providing hygiene, changing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-09 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and resident and staff interviews, the facility failed to provide a functioning resident call system for 1 of 2 residents reviewed for resident call system (Residents #1).The findings included:Resident #1 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, cerebrovascular accident (CVA) with hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side), chronic kidney disease, and chronic pain syndrome. The Care Plan revised 2/20/26 for Resident #1 had a focus for ADL (activities of daily living) self-care performance deficit with interventions to encourage the resident to use the bell to call for assistance and required supervision by 1 staff for toileting and personal hygiene. Resident #1's quarterly Minimum Data Set (MDS) on 3/25/26 indicated she was cognitively intact with adequate hearing and vision. She was coded as no impairment for upper extremity functional mobility. An interview was conducted with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and resident and staff interviews, the facility failed to provide care in a manner that maintained the resident's dignity by not providing incontinence care when needed. Resident #102 stated it made her feel bad having to wait a long time to be changed. This occurred for 1 of 3 residents reviewed for dignity (Resident #102).The findings included:Resident #102 was admitted to the facility on [DATE].The admission Minimum Data Set assessment dated [DATE] indicated Resident #102 was cognitively intact, had adequate vision, required substantial/maximal assistance with toileting hygiene and was frequently incontinent of both urine and bowel.During a continuous observation on 3/30/26 from 1:24 PM to 2:00 PM, an interview was conducted with Resident #102 who was lying in bed in her room. Resident #102's call light was not on at the start of the observation. There was a faint odor of urine and feces upon entry into Resident #102's room. Resident #102 stated that she always had to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, the facility failed to notify law enforcement and Adult Protective Services (APS) for an initial allegation of injury of unknown origin. The facility also failed to submit a 5-day investigation report to the state agency within the required timeframe for 1 of 1 resident with an allegation of injury or unknown source (Resident #105). 1. Review of the facility policy dated 6/1/25 abuse, neglect and exploitation stated the facility was to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prevent abuse, neglect, exploitation and misappropriation of resident property.2. The procedure included:7. (A) The facility will have written procedure for reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes. A. Immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Power of Attorney, staff, Ombudsman, Hospital Case Manager and Medical Director interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric evaluation. Resident #101 remained in the hospital for 11 days despite being cleared to return to the nursing home and was eventually discharged home. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #101).The findings included:Resident #101 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, post-traumatic stress disorder (PTSD), bipolar disorder, delusional disorders and cataract.A review of a Change in Condition form for Resident #101 dated 2/6/26 at 8:47 AM indicated the resident was found lying in bed with a safety razor in hand and copious amount of blood on hands, wrists and abdomen. Multiple shallow lacerations noted to bilateral…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with serious mental health disorders for 1 of 3 residents reviewed for PASRR (Resident #101).Findings included:A PASRR Determination Notification letter dated 9/04/25 revealed Resident #101 had a Level I PASRR with no expiration date.Resident #101 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, bipolar disorder in remission and delusional disorders. She was also diagnosed with major depressive disorder, single episode, severe with psychotic features. Resident #101's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #101's active psychiatric/mood disorder diagnoses included depression, bipolar disorder, psychotic disorder and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews with residents and staff, the facility failed to provide incontinence care (Resident #102) and showers as scheduled (Resident #77) for 2 of 6 dependent residents reviewed for assistance with activities of daily living.The findings included:1. Resident #102 was admitted to the facility on [DATE] with diagnoses that included pneumonia, weakness and reduced mobility.The admission Minimum Data Set assessment dated [DATE] indicated Resident #102 was cognitively intact, had adequate vision, required substantial/maximal assistance with toileting hygiene and was frequently incontinent of both urine and bowel.Resident #102's care plan initiated on 2/24/26 indicated Resident #102 had an activities of daily living (ADL) performance deficit. Interventions included Resident #102 required maximum assistance by 1 to 2 staff for toileting. Further review of Resident #102's care plan indicated she had bladder incontinence. Interventions included change disposable briefs…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, the facility failed to complete an accurate Minimum Data Set (MDS) in the areas of behaviors, wandering, and the use of a wanderguard bracelet (used to protect residents from elopement) for 1 of 2 residents review for accuracy of assessments (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), cognitive communication deficient and unspecified symptoms and signs involving cognitive functions and awareness. On 10/29/25 the Medical Director added the diagnosis adjustment reaction with aggression. The admission assessment dated [DATE] indicated that Resident #1's mood was described as combative with staff, and his behavior was physically abusive. On 10/26/25 a behavioral note indicated that Resident #1 was exit seeking and unable to be redirected. He was striking staff and knocked over a water dispenser. Resident #1 had been up all night wandering the unit searching for exits. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · E2025-03-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to date opened containers of thickened liquids and clean 1 of 1 reach-in refrigerators. The facility also failed to remove expired chocolate milk from a nourishment room (the Secured Unit nourishment room). These practices had the potential to affect food served to the residents. Findings included: a. On 3/3/25 at 9:51 AM an observation of the reach-in refrigerator in the kitchen found 3 containers of thickened liquid that were opened and did not contain an open date. The Dietary Manager (DM) stated during the observation he thought the thickened liquids were used for breakfast, but should have been dated before storing in the refrigerator. On 3/3/25 at 9:54 AM the bottom of the reach-in refrigerator was observed with a sticky to touch residue. The bottom of the refrigerator also contained food debris spread around the bottom of the refrigerator. The DM stated during the observation that he was unsure when the refrigerator was last cleaned. The DM stated he started working as the facility's DM the previous week and was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to develop an accurate baseline care plan for a resident (Resident #303) when the care plan did not include the indwelling catheter that was present on admission for Resident #303. This deficient practice occurred for 1 of 2 residents reviewed for baseline care plans. Findings included: Resident #303 was admitted to the facility on [DATE]. An admission nursing assessment dated [DATE] completed by Nurse #1 documented under the section genitourinary, a catheter was used. The admission Minimum Data Set assessment had not been completed yet. A baseline care plan dated 2/28/25 was not marked for an indwelling catheter. An observation was conducted on 3/3/25 at 11:20 AM of Resident #303 in her room in bed with an indwelling catheter draining to a bedside drainage bag. An order dated 3/4/25 read, [indwelling] urinary catheter 14 french with 10 milliliter (ml) balloon. An interview was conducted on 3/6/25 at 10:07 AM with Nurse #1. She…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop an accurate comprehensive care plan for a resident (Resident #10) when the care plan did not include a plan of care for pain. This deficient practice occurred for 1 of 1 resident reviewed for pain. Findings included: Resident #10 was admitted to the facility on [DATE] with the following diagnoses: unspecified fracture of shaft of left femur, unspecified fracture of upper end of left humerus. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively intact. The MDS documented that she had moderate pain, at a frequency of almost constantly, and she received as needed (PRN) pain medication. The MDS further documented that she received an opioid medication. The Care Area Assessment 2/11/25 revealed Resident #10 had triggered for pain and indicated she should be care planned for pain. A physician order dated 2/13/25 read, oxycodone (pain medication) 5 milligrams (mg) oral tablet, give 2.5 mg by mouth…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to ensure the resident had medical diagnoses to support an indwelling urinary catheter and to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 1 resident reviewed with a urinary catheter (Resident #303). Findings included: Resident #303 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation and chronic obstructive pulmonary disease (COPD). A Discharge summary dated [DATE] did not include information or an indication for Resident #303's indwelling catheter. An admission nursing assessment dated [DATE] completed by Nurse #1 documented under the section genitourinary, a (urinary) catheter was used. The admission Minimum Data Set assessment had not been completed yet. A baseline care plan dated 2/28/25 was not marked for an indwelling catheter. An order dated 3/4/25 read, [indwelling] urinary catheter The order did not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident, and staff interviews, the facility failed to ensure that oxygen air filters were present, clean, and without dust for 2 of 3 residents reviewed for respiratory care (Resident #25 and Resident #78). The findings included: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #25's cognition was moderately impaired. A review of physician orders dated 03/03/2025 at 7:00 AM revealed an order for continuous oxygen at 2 liters per minute via nasal cannula every shift. An observation conducted on 03/03/2025 at 1:08 PM, Resident #25 was observed lying in bed with his head of bed elevated. His oxygen cannula was in place to both nostrils with an oxygen setting of 2 liters per minute. The oxygen concentrator had a place for an oxygen air filter, and it was noted that the filter was missing as was the filter cover. An…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Nurse Practitioner (NP), and Consultant Pharmacist interviews, the facility failed to act on a pharmacy recommendation to add a stop date for a PRN antipsychotic medication (Resident #17). This deficient practice occurred for 1 of 5 residents reviewed for pharmacy recommendations. Findings included: Resident #17 was admitted on [DATE] was diagnosis that included post-traumatic stress disorder (PTSD), schizophrenia and bipolar disorder. A review of Resident #17's physicians orders found an active order dated 12/1/24 for Haloperidol injection solution inject 5 milligrams (MG) intramuscularly every 4 hours as needed (PRN) for agitation. A December pharmacy recommendation dated 12/2/24 read in part Resident #17 had an order for Haloperidol without a stop date. The review wrote PRN antipsychotic orders were only good for a maximum of 14 days. The recommendation was signed by the NP on 3/5/25 and agreed to stop the PRN medication. A review of Resident #17's quarterly minimum data set…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Pharmacy Representative, and Nurse Practitioner (NP) interviews, the facility the facility failed to include a 14- day stop date with an order for a PRN antipsychotic medication (Resident #17). This deficient practice occurred for 1 of 5 residents reviewed for pharmacy recommendations. Findings included: Resident #17 was admitted on [DATE] was diagnosis that included post-traumatic stress disorder (PTSD) and schizophrenia bipolar disorder. A review of Resident #17's physicians orders found an active order dated 12/1/24 for injection solution, inject 5 milligrams (MG) intramuscularly every 4 hours as needed (PRN) for agitation. A review of Resident #17's quarterly minimum data set (MDS) dated [DATE] had coded her as severely cognitive impaired. She was coded yes for taking an anti-psychotic medication. The Director of Nursing (DON) was interviewed on 3/06/25 at 1:11 PM. The DON stated the PRN antipsychotic medications needed a 14-day stop date. The DON said after 14 days, the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0807 — failed to offer suitable drinks — isolated
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to provide drinks consistent with the resident's thickened liquid needs for 1 of 1 sampled resident (Resident #73) reviewed for drinks available to meet resident needs. Findings included: Resident #73 was admitted on [DATE] with diagnoses that included dementia and dysphagia. Resident #73's quarterly Minimum Data Set (MDS) dated [DATE] was reviewed. Resident #73 was coded for severe cognitive impairment. Resident #73 was also coded for receiving a mechanically altered diet. Resident #73 had a physician's order dated 12/4/24 for regular diet, dysphagia puree texture with honey thickened fluids. On 3/6/25 at 12:25 PM in the locked unit dining room, the Speech Therapist notified the surveyor Resident #73 received thin liquids on his meal tray. The Speech Therapist said Resident #73 needed honey thickened liquids for safe swallowing, and it was written on the meal ticket. Resident #73 was observed sitting at a table with a family member…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-26 · tag F0552 — pattern
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, Responsible Party (RP) interview, Psychiatric Nurse Practitioner interview, staff and physician interviews, the facility failed to communicate and provide information in a language the resident could understand for a resident that did not speak or understand the English language for 1 of 1 resident reviewed for communication (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses which included social pragmatic communication disorder (persistent difficulty with verbal and nonverbal communication) and altered mental status. The care plan initiated on 6/22/23 revealed Resident #43 was at risk for social isolation related to cognitive impairment and language barrier, speaks Romanian with interventions which included provide one on one activities as needed to prevent social isolation and to use communication board as needed. A care plan was initiated on 7/04/23 for communication problem related to impaired ability to make…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-26 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, resident and staff interviews, the facility failed to resolve repeat concerns regarding cold food temperatures and late meal delivery reported during the Resident Council meetings for 10 of 13 months (October 2022, November 2022, December 2022, January 2023, Feburary 2023, March 2023, May 2023, June 2023, July 2023, and October 2023) months reviewed. Findings included: Record review of October 2022 Resident Council meeting revealed concerns related to delayed laundry and late meal delivery were presented. Record review of November 2022 Resident Council meeting revealed concerns related to late meal delivery and laundry delayed. The minutes revealed there was no response from the facility about late meal delivery and delayed laundry from October 2022 resident council meeting minutes. Record review of December 2022 Resident Council meeting revealed concerns related to meals not being consistent and late meal delivery. The Administrator was present at the December 2022 meeting. She spoke about housekeeping and dietary staffing challenges. Record review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-26 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and nurse practitioner interview the facility failed to transcribe and implement the nurse practitioner orders for two (Resident #30, Resident #21) of three residents reviewed for professional standards of practice. The Findings included: 1.Resident #30 was admitted to the facility on [DATE] with diagnoses that included hypoglycemia, chronic oppressive pulmonary disease, anxiety, end stage renal disease, atrial fibrillation, and congestive heart failure. Review of the Minimum Data Set, dated [DATE] revealed she was assessed as having severely impaired cognition. Review of the facility Nurse Practitioner Acute Concern for the Doctor. note dated 10/20/23 revealed an order 1. Increase Amlodipine to 10 milligram po Daily. 2. Daily BP (blood pressure) x 5 days. (take at noon or later) (manual BP only). Review of Resident #30's Medication Administration record for October 2023 revealed blood pressure was checked on 10/20/23 and no further documentation of blood pressure checks…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to offer hand hygiene to residents before meals when staff delivered lunch meal trays to resident rooms for 2 of 3 observations completed for dining (Resident #86, Resident #58, Resident #6, Resident #83, Resident #37, and Resident #147). The findings included: The facility policy titled Infection Prevention and Control Program last revised in October 2018 revealed the Infection Prevention and Control (IPCP) was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's Handwashing/Hand Hygiene Policy last revised August 2019 revealed the facility considered hand hygiene the primary means to prevent the spread of infections and that residents will be encouraged to practice hand hygiene. The policy further stated in part that alcohol-based hand rub or soap and water was to be used before…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff, resident, and Physician interviews the facility failed to protect a resident's right to be free of misappropriation of narcotic pain medication for 2 of 3 residents (Resident #27 & #247) reviewed for misappropriation of property. The findings included: a. Resident #27 was admitted to the facility on [DATE] with diagnoses that included a history of a left knee fracture and osteoarthritis. A review of Resident #27's Controlled Medication Utilization Record initiated on 6/29/23 revealed 4 medication cards containing 30 pills of Oxycodone 10mg were received from the pharmacy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was moderately cognitively impaired, required limited assistance from 1 staff member to complete activities of daily living, and was not coded as requiring pain medication. A review of Resident #27's July 2023 Physician's orders revealed an order for Oxycodone 10 milligram (mg) 1 tablet by mouth 4 times daily that was discontinued by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to follow their policy related to misappropriation of property and exploitation in the areas of reporting to the state, investigating an allegation of misappropriation and exploitation, and protecting residents at risk as a result of not investigating. In addition, the Administrator failed to identify an allegation of misappropriation and exploitation when reported to her by the Business Office Manager. This was for 1 of 3 residents (Resident #397) reviewed for misappropriation of property. Findings included: The facility Policy and Procedures revised on 11/16/2022 stated, Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent. Employee Misappropriation includes but is not limited to: Identity theft; Theft of money from bank accounts; Unauthorized or coerced purchases on a resident's credit card; Unauthorized coerced…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop an individualized person-centered care plan in the area of dementia for 1 of 3 residents reviewed for dementia care (Resident #40). The findings included: Resident #40 was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #40 was cognitively intact and was coded for a dementia diagnosis. Review of Resident #40's care plan last reviewed on 7/6/23 revealed there was not a care plan in place for Resident #40's dementia diagnosis. An interview was conducted with Unit Manager #1 on 10/26/23 at 8:41 am who revealed the MDS Nurse was responsible for resident care plans. During an interview on 10/26/23 at 8:55 am the MDS Nurse stated she was not responsible for developing the cognitive portion of resident care plans. The MDS Nurse stated the Social Worker was responsible to develop Resident #40's care plan for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, the facility failed to place hand/wrist splint to the left hand for contracture management for 1 of 1 resident reviewed for limited range of motion (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, Parkinson's disease, and dementia. Review of Resident #19's active physician orders on 10/23/23 revealed an order dated 4/12/22 to wear left wrist splint while up in wheelchair as tolerated. Resident #19's care plan last reviewed on 4/11/23 revealed a care plan for the left wrist splint to wear at all times when up in wheelchair as tolerated and to check skin integrity of left wrist every shift. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #19 had severe cognitive impairment, he had clear speech, was able to clearly make his needs known, and he was able to understand others with clear comprehension. He was coded for limited…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations and staff interviews the facility failed to discard expired medications stored for use in 1 of 1 medication storage room reviewed for medication storage. The findings included: On 10/26/23 at 9:30am an observation was completed of the medication storage room with the Director of Nursing (DON). The observation revealed 1 multidose vial of opened and accessed Tuberculin Purified Diluted solution with an opened date of 9/14/23 located in the medication refrigerator. A review of the manufacturer's instruction label on the box indicated the medication should be discarded 30 days from the date medication was opened. An interview was completed on 10/26/23 at 9:35am with the DON. She indicated it was the Unit Manager's responsibility to check the medication room for expired medications. The DON stated the expired medication should have been discarded or returned to the pharmacy. An interview was completed on 10/26/23 at 10:01am with Unit Manager #1. The Unit Manager stated she checked the medication room monthly for expired medications. She revealed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to administer the pneumococcal vaccination to an eligible resident for 1 of 5 residents reviewed for immunizations (Resident #158). The findings included: The facility policy, Pneumococcal Vaccine last reviewed October 2019, read in part residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty (30) days of admission unless medically contraindicated or previously vaccinated. The policy further stated for residents that receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. Resident #158 was admitted to the facility on [DATE] with diagnoses which included dementia and diabetes. Review of the Informed Consent for Pneumococcal Vaccine record dated 7/11/23 revealed the Resident Representative (RP) accepted and gave the facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-10-26 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident and staff interviews, Facility failed to inform residents (Residents #52, #47, #2, #49, #40, #150, #76, #17, and #21) of the location of the most recent survey results and failed to display the survey results in a location accessible to residents. Findings: During an initial tour of the building on 10/23/2023 at 11:09 A.M. survey results were unable to be located. No signage was observed posted regarding the availability and location of survey results. A Resident Council meeting was conducted on 10/25/2023 at 11:25 A.M. During the meeting 9 of 9 residents, (Residents #52, #47, #2, #49, #40, #150, #76, #17, and #21) stated they did not know where the survey results were located and had not seen any signage that directed residents to the location. Residents #21, and #76 stated they wished to review the state survey results binder but did not know its location. During an interview with the Activities Director on 10/25/2023 at 12:08 P.M. She stated she did not know where the state survey results were located. In an interview with the Director of Nursing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • No harm found · Bcited before2023-10-26 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 2 of 24 sampled residents whose MDS assessments were reviewed (Resident #43 and Resident #17). The findings included: 1. Resident # 43 was admitted to the facility on [DATE]. Record review of the Change in Condition assessment dated [DATE] revealed Resident #43 had a fall at 12:00 pm and later complained of pain to right lower ankle and tibia (shin bone). An x-ray was ordered. The radiology report dated 8/10/23 revealed Resident #43 had an avulsion fracture (a small chunk of bone attached to tendon/ligament gets pulled from the main part of the bone). Review of Resident #43's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed she was not coded for the fall or fall with injury. An interview was conducted on 10/24/23 at 12:50 pm with the MDS Nurse who revealed she was aware of Resident #43's fall and the quarterly assessment should have been coded for the fall. The MDS Nurse…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$73,475 in federal fines across 2 penalties.

  • $62,607 — penalty dated 2026-04-09
  • $10,868 — penalty dated 2025-03-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to AVARDIS HEALTH — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.0-1.0 vs chain
Health inspection 1 of 51.9-0.9 vs chain
Staffing 4 of 52.3+1.7 vs chain
Quality measures 2 of 53.2-1.2 vs chain
The other 37 homes this chain runs (chain average 2.0★, per CMS)
1 of 5Ashland Nursing And RehabilitationAshland, VA 1 of 5Augusta Nursing and RehabilitationFishersville, VA 1 of 5Biltmore Haven Nursing and RehabilitationArden, NC 1 of 5Courtyard Health And RehabilitationMcComb, MS 1 of 5Ghent Health and RehabilitationNorfolk, VA 1 of 5Grand Trace Health And RehabilitationNatchez, MS 1 of 5Hibriten Mountain Nursing and RehabilitationLenoir, NC 1 of 5Highfield Nursing and RehabilitationCary, NC 1 of 5Kings Daughters Community Health & RehabStaunton, VA 1 of 5Middleton Oaks Health And RehabilitationWinona, MS 1 of 5Newport News Nursing & RehabNewport News, VA 1 of 5Pennknoll VillageEverett, PA 1 of 5The Oaks Rehabilitation And Healthcare CenterMeridian, MS 1 of 5Wellington Rehabilitation and HealthcareKnightdale, NC 1 of 5Westwood Health and RehabilitationArchdale, NC 1 of 5Woodstock Valley Health and RehabilitationWoodstock, VA 2 of 5Clay County Health and RehabilitationHayesville, NC 2 of 5Crown Haven Health and RehabilitationCharlotte, NC 2 of 5Kannapolis Health and RehabilitationKannapolis, NC 2 of 5Manor At Penn Village, TheSelinsgrove, PA 2 of 5Manor At St Luke Village,theHazleton, PA 2 of 5Pavilion At St Luke Village, TheHazleton, PA 2 of 5Pheasant Ridge Nursing and RehabilitationRoanoke, VA 2 of 5Valley View Care and RehabilitationAndrews, NC 2 of 5Walnut Cove Health and RehabilitationWalnut Cove, NC 2 of 5Wilora Lake HealthcareCharlotte, NC 2 of 5Windsor Grove Health and RehabilitationWindsor, VA 3 of 5Forrest Oakes HealthcareAlbemarle, NC 3 of 5Hilltop Manor Health And Rehabilitation CenterUnion, MS 3 of 5Locust Grove Retirement VillageMifflin, PA 3 of 5Skyline Nursing & RehabilitationFloyd, VA 4 of 5Jamestown Health and RehabilitationWilliamsburg, VA 4 of 5Oak Grove HealthcareRutherfordton, NC 4 of 5Willowbrook Rehabilitation and CareYadkinville, NC 5 of 5Cardinal Healthcare and RehabilitationLincolnton, NC 5 of 5Grayson Health and RehabilitationIndependence, VANot rated (Special Focus)Starkville Manor Health Care And Rehabilitation CeStarkville, MS

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
ASHEVILLE PARENTCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 06/01/2025
NCOP HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
NU C II IRREVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
NU C IRREVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
RMB HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
SNF CARE CENTERS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
ZENITH HOLDCO II LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
ZENITH HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 06/01/2025
CSE WOODFIN LPOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 06/01/2025
HOBACK, TIFFANYIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
SEMONES, BRANDIIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
SNF MGR LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
CRUM, KATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
FISHER, CANDACEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
JONES, TEQUILLAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025
RAMSEY, REBECCAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2025

CMS files one row per role, so the 26 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.5M
Net patient revenuemost recent cost report
+16.6%
Operating marginrevenue minus expenses
$586K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 6%Other / private 18%

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $586K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$278per resident / day
operating cost
$8,444per month
≈ monthly operating cost
$333per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 345447. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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